Received: 21 March 2023 | Accepted: 19 September 2023

DOI: 10.1111/aos.15785

ORIGINAL ARTICLE

Accommodative–­vergence disorders in a paediatric ophthalmology

clinical setting in Argentina

Alejandra Iurescia1 | Rafael Iribarren2 | Carla Lanca3,4 | Andrzej Grzybowski5,6

1
Dr. Iurescia Eye Consultant, Quilmes,
Argentina Abstract
2
Drs. Iribarren Eye Consultants, Buenos Purpose: To determine the frequency of potential non-­ strabismic
Aires, Argentina accommodative–­vergence anomalies (NSAVA) and investigate associations be-
3
Escola Superior de Tecnologia da Saúde de tween NSAVA, refractive errors and age among children attending a paediatric
Lisboa (ESTeSL), Instituto Politécnico de
Lisboa, Lisboa, Portugal ophthalmology clinic.
4
Comprehensive Health Research Center Methods: This study included children and adolescents aged 5–­19 years attend-
(CHRC), Escola Nacional de Saúde ing an ophthalmology clinic with at least two follow-­up visits. At their first
Pública, Universidade Nova de Lisboa, visit, children had a comprehensive ophthalmic examination, including re-
Lisboa, Portugal
5
fractive error measurement by cycloplegic autorefraction and spectacles were
Department of Ophthalmology, University
of Warmia and Mazury, Olsztyn, Poland prescribed if necessary. At the second visit, children had an examination of
6
Institute for Research in Ophthalmology, best-­corrected visual acuity, convergence and accommodation to identify po-
Poznań, Poland tential NSAVA. The relationship between age, sex, heterophoria and refractive
error and potential NSAVA was assessed by a multivariable logistic regression
Correspondence
Andrzej Grzybowski, Foundation for model.
Ophthalmology Development, Institute Results: A total of 384 children and adolescents were evaluated. Their mean age
for Research in Ophthalmology, ul. was 10.97 ± 3.07 years and 58.9% were females. Forty-­two per cent of children
Mickiewicza 24/3B, Poznań 60-­836, Poland.
Email: [email protected] failed the NSAVA tests and 34.1% had myopia (≤−0.50 D). Children who failed
NSAVA tests self-­reported a higher proportion of reading problems (73.7%)
compared to those who passed the tests (26.3%; p < 0.001). Children with self-­
reported reading problems were more likely to have accommodative infacility
(57.9%) compared with children without (42.1%; p < 0.001). Refractive error and
age were not associated with failure in NSAVA tests (p > 0.05).
Conclusions: NSAVA was a frequent cause of vision problems found in a sample
of children from an ophthalmology paediatric clinic. Thus, further research is
necessary to understand the potential of public health policies to prevent, refer,
diagnose and treat those conditions.

K EY WOR DS
binocular vision, myopia, prevalence, reading

1 | I N T RODUC T ION improves binocularity. In a previous study, binocu-

lar vision dysfunction was reported to be associated
Non-­strabismic accommodative and vergence anom- with refractive error in Chinese young adults (Ma
alies (NSAVA) include accommodative insufficiency, et al., 2019). However, there is mixed evidence with one
accommodative excess and accommodative infacil- study in African high school students reporting no as-
ity as well as convergence insufficiency, convergence sociation with binocular vision dysfunction and refrac-
excess and fusional vergence dysfunction. These are tive error (Wajuihian, 2017).
vision anomalies which reduce binocular coordina- There are no data on the frequency of NSAVA in chil-
tion and visual efficiency. The symptoms of NSAVA dren attending ophthalmic paediatric practices in Ar-
include headaches, eyestrain, loss of comprehension gentina. These dysfunctions may be missed if a thorough
and avoidance of near work. The burden and conse- examination is not performed (Mandal & Kamath, 2020).
quences of NSAVA are numerous and include nega- In this study, we aimed to determine the frequency of as-
tive impact on the child's quality of life and academic pects of NSAVA using simple tests that any ophthalmol-
performance. Baseline treatment of refractive errors ogist can perform in everyday practice to further refer

© 2023 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

Acta Ophthalmologica. 2023;00:1–6.  wileyonlinelibrary.com/journal/aos | 1

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2    IURESCIA et al.

those patients to an orthoptic evaluation. The goal of (SE = sphere + ½*cylinder). Myopia was defined by an
this study was to highlight the need for eye care practi- SE of less than or equal to −0.50 dioptres (D) and high
tioners to routinely test for NSAVA as these dysfunctions myopia by an SE of less than or equal to −5.00 D. Em-
may be missed out unless a complete orthoptic and bin- metropia was defined by an SE ranging between >−0.50
ocular vision examination is performed. The intention D and +0.50 D. Hyperopia was defined by an SE ranging
of the study is also to increase the awareness among eye between >+0.50 D and +2.00 D and high hyperopia by
care professionals to assess symptomatology and per- an SE greater than +2.00 D. Anisometropia was defined
form simple diagnostic tests to identify NSAVA with by a difference of 1.00 D or more between the SE of both
subsequent referral to orthoptic evaluation. Findings eyes and anisoastigmatism was defined by a difference of
are important for policy administration and planning of 1.00 D or more in the astigmatism of both eyes.
ophthalmological services. The specific objectives of the
study are to: (1) determine the frequency of NSAVA and
(2) investigate associations between NSAVA, refractive 2.2 | Visual acuity and accommodative and
errors and age. The hypothesis tested was that there was vergence assessment (second visit)
no significant association between NSAVA and refrac-
tive error and age. At the second visit, consecutive unselected children and
adolescents who came to the clinic for routine ocular an-
nual examination had a comprehensive examination of
2 | M AT E R I A L S A N D M ET HOD S best-­corrected visual acuity, convergence and accom-
modation. All included children had measures of re-
This was an observational study which examined chil- fractive error with cycloplegia from their first visit. The
dren and adolescents aged 5–­19 years with at least two follow-­up time between the first and second visit was 6
follow-­up visits in an ophthalmology paediatric clinic to 12 months. Best-­corrected visual acuity at the second
located in Quilmes, Greater Buenos Aires, Argentina. visit was compared with the first visit to ensure that re-
Data were collected between October and November fraction had not changed. Figure 1 shows the flow chart
2021. All children attending the clinic have annual or of the study design. In Argentina, it is common to main-
semi-­annual visits for routine ocular examinations. Chil- tain regular ophthalmological annual follow-­ups until
dren with acute conjunctivitis, chalazion, blepharitis, the age of 20 years, even if previous examinations are
trauma or other acute pathologies were excluded from normal. All visual functions were assessed with previ-
the study. Patients with ocular pathologies, such as colo- ously prescribed spectacles, if applicable. Best-­corrected
boma, congenital glaucoma, Duane syndrome, history visual acuity was measured with a retro-­ illuminated
of strabismus surgery, anterior polar cataract, retinopa- Snellen Optotype Projector (Tumbling E, Rusner, Ar-
thy of prematurity or amblyopia were also excluded. The gentina). Accommodative–­vergence assessment included
study was conducted in accordance with the tenets of the the near point of convergence (NPC), heterophoria meas-
Declaration of Helsinki. Verbal assent from the children urement at near and accommodative facility testing.
and verbal consent from the parents was obtained from NPC was measured using the push up technique with an
all subjects after the nature of the study was explained. accommodative target and a ruler. NPC was measured
As there was no therapeutic intervention within the pro- three times and registered as insufficient when it was
tocol, the current legislation in Argentina does not con- greater than 5 cm. Previous studies suggested that chil-
sider authorization by an accredited ethics committee dren below 8 years have lower NPC and the use of NPC
to be necessary. Nevertheless, The Argentinian Council >5 cm may be important to differentiate symptomatic el-
Ethics Committee was consulted and as no intervention ementary school children and adults (Chen et al., 2000;
or new test was administered, the Committee suggested Maples & Hoenes, 2007; Scheiman et al., 2003).
that approval was not necessary. Data were completely The heterophoria was measured with Thorington
anonymized and in full compliance with data protection phoria test with an accuracy of 1 prismatic diopter
laws. (PD) and a millimetric chart held at 33 cm (provided
by Lab. Pfortner, Argentina). Normal heterophorias
were considered in the range from 2 PD esophoria to 8
2.1 | Refractive error assessment (first visit) PD exophoria (Dwyer, 1991). Negative values indicate
exophoria and positive values indicate esophoria. The
At their first visit, children and adolescents attending the presence of a vertical heterophoria of 1 PD or more was
clinic were submitted to a comprehensive ophthalmic ex- considered an abnormal result. Monocular accommoda-
amination, including visual acuity and routine refractive tive facility (MAF) test for each eye was measured with
error measurement by cycloplegic autorefraction. Cy- ±2.00 D flippers using a 0.6 M letter at 0.4 m for a period
cloplegia was induced with two drops of cyclopentolate of 1 min (expressed in accommodative facility cycles per
1% instilled in each eye 5 min apart. Subsequently, cy- minute). Insufficient values were considered when MAF
cloplegic autorefraction was performed with a handheld was below six cycles per minute. A child was considered
auto-­refractor (2WIN, Adaptica, Italy) at least 40 min to have potential NSAVA when NPC >5 cm or MAF <6
after the last eye drop. When necessary, spectacles were cycles per minute. The examination also included a de-
prescribed according to the American Academy of Oph- tailed general medical and ophthalmic history allowing
thalmology Clinical Practice Patterns. Spherical equiv- the patient to self-­report visual symptoms such as head-
alent (SE) was calculated using the standard formula aches and reading problems in a non-­structured pattern.
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IURESCIA et al.    3

FIRST VISIT: Ophthalmic examination, including comprehensive examination

of visual acuity and refractive error measurement by cycloplegic autorefraction.

Excluded from the study: children with

If necessary, spectacles acute conjunctivitis, chalazion, blepharitis,
were prescribed according trauma, or other acute pathologies. Patients
to the American Academy with ocular pathologies, such as coloboma,
of Ophthalmology Clinical congenital glaucoma, Duane syndrome,
Practice Patterns. history of strabismus surgery, anterior polar
cataract or retinopathy of prematurity.

ENROLEMENT (SECOND VISIT)

Consecutive unselected children:

Comprehensive examination of best corrected Excluded from
visual acuity, convergence, accommodation, and the study: children
assessment of self-report visual symptoms. with amblyopia.

ANALYSIS

Identification of potential non-strabismic

anomalies of binocular vision

FIGURE 1 Flow chart of the study design.

2.3 | Statistical analysis 3 | R E SU LT S

The sample size calculation for an expected propor- A total of 384 children and adolescents were included in
tion of 20% frequency of binocular disorders with a the analysis. The mean (± standard deviation) age was
p = 0.05 and a precision of 4% rendered a sample of 384 10.97 ± 3.07 years, and 226 (58.9%) were females (Table 1).
subjects. Means and standard deviations were calcu- Their mean cycloplegic SE was −0.18 ± 1.92 D. The mean
lated for linear variables and percentages for discrete near phoria was −1.22 ± 4.70 PD. In total, 47.4% of the
variables. To determine which risks factors were as- children had orthophoria, 33.9% had esophoria and
sociated with the failure in accommodative–­vergence 17.7% had exophoria.
tests, we compared age, gender, heterophoria and SE The frequency of refractive errors, strabismus and po-
in children who failed the tests (n = 162) and children tential NSAVA is provided in Table 2. Myopia was diag-
who did not fail the tests (n = 186) after excluding chil- nosed in 34.1% of the children and high myopia in 1.8%
dren with strabismus from the analysis. The outcome (total of 35.9%). In children aged 5–­11 years, the most pre-
potential NSAVA was analysed as a categorical vari- disposed to develop high myopia in adulthood, there were
able (with anomalies/without anomalies). Analyses 61 children with myopia. Older children (12–­ 19 years)
of associations were performed using a multivari- had significantly higher myopic SE (−0.88 D vs. −0.04 D;
able logistic regression model. Risk factors such as p < 0.001) compared with younger children (5–­11 years).
age, heterophoria and SE were analysed as continu- Thirty-­five (9.1%) children had anisometropia and 39
ous variables (per unit change). SE of right and left children (10.2%) had an anisoastigmatism of more than
eyes was highly correlated (r = 0.89, p < 0.001) so the 1.00 D. There were 10 children (2.6%) with an anisoastig-
analysis was performed with the SE of right eyes only. matism of 2.00 D or more. Self-­reported reading problems
Odds ratios (OR) were estimated using backward step- were referred by 9.9% (n = 38) of children and headaches
wise multivariable logistic regression model. A value by 4.2% (n = 16) children.
of p < 0.05 was chosen for statistical significance. All Forty-­two per cent of children and adolescents failed
statistical analyses were carried out with SPSS (IBM, the accommodative–­ vergence tests, including children
United States, version 26). with an NPC >5 cm (12.3%) or MAF <6 cycles per minute
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4    IURESCIA et al.

T A B L E 1 Demographic and eye characteristics of included problems (73.7%) compared with children who did not fail
children in the study (n = 384). the tests (26.3%; p < 0.001). Children with reading problems
Demographic and eye Number of Mean ± SD
were more likely to have accommodative infacility (57.9%)
characteristics children or % compared with children without accommodative infacility
(42.1%; p < 0.001). There were no significant differences
Age (years) 383 10.97 ± 3.07
between the proportion of self-­reported reading problems
Age groups (%)
and refractive error (p = 0.28) or the proportion of accom-
5–­11 years 241 62.9% modative infacility and refractive error (p = 0.84).
12–­19 years 142 37.1% There were no significant differences in SE by NPC groups
Gender (%) (NPC ≤5 cm = −0.10 ± 1.88 D; NPC >5 cm = −0.17 ± 2.14 D;
Boys 158 41.1% p = 0.74). SE was significantly more hyperopic in children
Girls 226 58.9%
with esophoria (0.55 ± 2.14 D) compared to children with
orthophoria (−0.10 ± 1.65 D; p = 0.004).
Spherical equivalent (D) 384 −0.18 ± 1.92
Heterophoria values were significantly different for hy-
Heterophoria (PD) 380 −1.22 ± 4.70
peropic children compared with emmetropic (0.41 ± 4.42
Orthophoria 182 47.9% PD vs. −1.48 ± 4.54 PD; p = 0.036) and high hyperopic chil-
Exophoria 68 17.9% dren (1.08 ± 4.62 PD; p = 0.021). Heterophoria values in hy-
Esophoria 130 34.2% peropic (p = 0.001) and high hyperopic (p = 0.001) children
also differed significantly compared with myopic children
Abbreviations: D, diopter; SD, standard deviation.
(−2.21 ± 4.60 PD). Although, there was a tendency for older
children (12–­19 years) to have higher exophoric values com-
T A B L E 2 Frequency and number of children and adolescents
with refractive errors, strabismus and potential accommodative–­ pared with younger children (5–­ 11 years), this tendency
vergence disorders (n = 384). was not significant (−1.85 vs. −1.03; p = 0.09). The correla-
tion between heterophoria values and age was not signifi-
Number of
cant (r = −0.07; p = 0.20). Similarly, the correlation between
Diagnosis children %
heterophoria values and SE was not significant (r = 0.09;
Refractive errors p = 0.10). Age by year (β = −0.05; 95% CI: −0.13–­ 0.03;
Myopia (SE −0.50 D to −4.99 D) 131 34.1% p = 0.20) and SE (β = 0.02; 95% CI: −0.02–­0.07; p = 0.26) were
High myopia (SE ≤−5.00 D) 7 1.8% not significantly associated with heterophoria values. There
Emmetropia (SE >−0.50 D to 0.50 D) 142 37.0% were no significant differences in the heterophoria values
Hyperopia (SE >0.50 D to 2.00 D) 69 18.0%
for NPC groups (p = 0.14). MAF was significantly lower in
children with NPC >5 cm (p = 0.08). Although, children with
High hyperopia (SE >2.00 D) 35 9.1%
myopia had lower MAF (9.11 cycles per minute) compared
Total 384 100%
with children without myopia (9.49 cycles per minute), the
Strabismus difference was not statistically significant (p = 0.42).
Accommodative strabismus 18 4.7% Potential NSAVA were associated with female sex (Odds
Intermittent exotropia 18 4.7% ratio [OR] = 1.62; 95% CI: 1.04–­ 2.52) and heterophoria
Potential non-­strabismic anomalies of binocular vision (OR = 1.07; 95% CI: 1.02–­1.13; Table 4) in the multivariable
Normal binocular vision 186 48.4%
model including age by year. Similar results were found
when age by groups as tested, with only gender (p = 0.029)
NPC >5 cm 47 12.2%
and heterophoria (p = 0.014) being significantly associated
MAF <6 cycles per minute 76 19.8% with NSAVA. In a subgroup analysis by age groups of 12–­
NPC >5 cm & MAF <6 cycles per 39 10.2% 19 years (n = 142) and 5–­11 years (n = 241), only female gen-
minute
der remained as significantly associated with NSAVA in the
Total 384 100% 5–­11 years group (OR = 2.35; 95% CI: 1.32–­4.21).
Abbreviations: NPC, near point of convergence; MAF, monocular
accommodative facility.
4 | DI SC US SION
(19.8%) or both (10.2%; Table 2). Among non-­strabismic
children, the mean MAF was 9.80 ± 4.76 cycles per minute. This study describes the frequency of potential NSAVA using
Potential accommodative–­vergence disorders were eval- simple tests among children and adolescents attending a pae-
uated in 348 children. Children with strabismus were ex- diatric ophthalmology clinic. Approximately 40% of children
cluded from the analysis (Table 3). Among non-­strabismic and adolescents failed those tests. The results of this study
children, those who failed the accommodative–­vergence show that mild disturbances of accommodation and vergence
tests were more likely to be girls (p = 0.020) and to have in non-­strabismic children are frequent in clinical practice in
exophoria (p = 0.028; Table 3). SE was not significantly this setting. Therefore, if this simple study is replicated and
different between the groups who failed or not the accom- confirmed, it may be necessary to educate paediatric oph-
modative and vergence tests (p = 0.87). Age by year or age thalmologists so that they can identify, treat and refer those
groups were also not significantly different between the children to orthoptics when necessary if a potential NSAVA
two groups of NSAVA and without NSAVA (p > 0.05). is suspected to further confirm the diagnosis.
Children who failed the accommodative–­ vergence tests Up to 9.9% of children and adolescents included in
reported higher proportion of self-­ reported reading this study spontaneously reported reading difficulties and
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IURESCIA et al.    5

T A B L E 3 Comparison of demographic characteristics, spherical equivalent, refractive error and heterophoria in children and adolescents
with and without potential accommodative–­vergence disorders (n = 348).

Potential accommodative–­vergence disordersa

Without anomalies With anomalies

Demographic characteristics n Mean ± SD or % n Mean ± SD or % p

Age (years) 185 10.8 ± 3.0 162 11.3 ± 3.2 0.18
Age groups
5–­11 years 122 56.2% 95 43.8% 0.16
12–­19 years 63 48.5% 67 51.5%
Gender
Boys 86 61.0% 55 39.0% 0.020
Girls 100 48.3% 107 51.7%
Spherical equivalent (D) 186 −0.32 ± 1.75 162 −0.29 ± 1.85 0.87
Myopia and high myopia 64 49.2% 66 50.8% 0.43
Emmetropia 74 54.8% 61 45.2%
Hyperopia and high hyperopia 48 57.8% 35 42.2%
Heterophoria (PD) 183 −0.68 ± 3.55 162 −2.02 ± 5.02 0.004
Orthophoria 94 53.1% 83 46.9% 0.028
Exophoria 22 38.6% 35 61.4%
Esophoria 67 60.4% 44 39.6%

Note: Mean ± standard deviation for continuous variables and percentages for categorical variables. p indicates difference in participant characteristics by outcome status.
Abbreviations: D, dioptre; n, number.
a
Potential accommodative–­vergence disorders were evaluated in 348 children. Children with strabismus were excluded from the analysis.

TA BL E 4 Association of key risk factors with potential accommodative–­vergence disorders (n = 348).

Demographic and eye characteristics Potential accommodative–­vergence disorders

Unadjusted OR (95% CI) p Multivariable OR (95% CI)a p
Age (years) 1.05 (0.98, 1.12) 0.18 1.04 (0.97, 1.11) 0.23
Gender (%)
Boys Reference Reference
Girls 1.67 (1.08, 2.58) 0.020 1.62 (1.04, 2.52) 0.033
Heterophoria (−1 PD increase) 1.08 (1.02, 1.13) 0.005 1.07 (1.02, 1.13) 0.013
SE (+1 D increase) 1.02 (0.90, 1.16) 0.72 1.07 (0.93, 1.22) 0.34

Abbreviations: CI, Confidence intervals; OR, Odds ratio.

a
Multivariate model includes age, gender, heterophoria and SE (n = 344).

among them 57.9% had accommodative infacility. There in those children may benefit performance in near vision
were no significant differences between the proportion of tasks. Additionally, orthoptic treatment may be necessary
children with reading problems and refractive error, or the (Shukla, 2020). Studies have shown that orthoptic treat-
proportion of children with accommodative infacility and ment including vergence and accommodative training is
refractive error. The results of the association between re- an effective method to treat and improve the symptoms
fractive error and reading problems in children have been (Chen et al., 2021; CITT-­ART Investigator Group, 2019;
mixed, with some studies reporting no association (Dusek Cooper et al., 1987; Weisz, 1979).
et al., 2010; Latvala et al., 1994). A recent meta-­analysis This study has several limitations. This was not a mul-
of five studies found that children with uncorrected hy- ticentric study; thus, the results may not represent the
peropia had worse educational performance and reading entire population. The participants were from Quilmes,
skills when compared with emmetropic and myopic chil- Greater Buenos Aires, which may induce cluster effects.
dren (Mavi et al., 2022). In another study, children with Patients who visit paediatric ophthalmology clinics are
uncorrected hyperopia had more reading errors, lower ac- more likely to have complaints of a visual anomaly than
curacy and lower reading speed when compared with chil- if they would have been selected at random from the
dren without hyperopia or with corrected refractive error general population. We found that a higher proportion
(Lanca, 2017). Correction of low-­ moderate hyperopia of children with anomalies of NPC and MAF reported
may increase speed of reading as there is an improvement reading problems compared with children who had no
in accommodative performance during sustained near anomalies of NPC and MAF. However, reading problems
activity in some school children (Ntodie et al., 2021; van were self-­reported and the study had a cross-­sectional
Rijn et al., 2014). Thus, prescribing hyperopic correction design. Thus, there may be a bias as reading anomalies
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6    IURESCIA et al.

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Dwyer, P.S. (1991) Clinical criteria for vergence accommodation dys-
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Vision Science, 73(4), 255–262.
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and accommodative facility results. Further research is young children? Binocular Vision & Strabismus Quarterly, 17(2),
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Failure in simple tests for accommodative–­vergence disor-
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